A few sobering facts about the building that will house your surgery center:

• It's the biggest capital line item in your project, and it will have the smallest impact on quality outcomes.
• There are no refunds - and it will cost more than you anticipated.
• And you only have one chance to get it right.

We spoke with architects and asked them to share with us the secrets to designing a successful surgical facility.

Team-building
When you recruit your team of experts, our architects advise you to look first and foremost for healthcare experience, especially with surgical facilities. They also agree that getting the developer, architect, engineer, contractor, lawyer, equipment planner, interior designer, consultants and lenders involved as early as possible can help reduce future change orders.

"Everyone wants to reduce change orders. If you work with a team of professionals, you can deal with most changes in the design phase," says Mike Gordon, an architect with Gordon & Associates of Mount Dora, Fla. "It's much easier and more cost-effective to erase a line during the design process than to tear down a wall."

Before hiring a general contractor, check his credentials with the state registrar of contractors, and find out if anyone's filed complaints against him, says Neil Terry, an architect with the Orcutt/Winslow Partnership in Phoenix. Check references, too, says Lynn App, an architect from Englewood, Ohio. "Talk to former clients and visit completed projects," she says. Ask questions like these:

• Did the design meet your needs?
• Was the project completed on schedule and on budget?
• How was the general working relationship?
• Did you and the architect work well together?

In addition to finding an architect with surgery center experience, you might want to consider an architect with experience in your state, as state regulations vary.

Develop your own team of decision-makers, including physicians, administrators and nursing staff, but don't go overboard. "It works well if you have two to five key decision-makers," says Mr. Cantrell. "Include an administrator and the director of nursing, who can be involved in every planning step. Then bring the recovery nurses into the meeting on the PACU and peri-operative nurses into the meeting on the ORs."

New vs. existing spaces
Renting or buying an existing building can save money, but our architects warn that you can't cheaply turn every building into a surgery center. "Look for one that is classified as institutional occupancy. Business occupancies, such as office buildings and even medical offices, have very different codes," says Mr. Terry. "You may to add a sprinkler system and fire-protection walls." "If you're above the first floor, you risk inconveniencing other tenants when you tear up their ceiling to get the gas line into the OR. It can get to be cost-prohibitive," says John Cantrell of the Orcutt/Winslow Partnership.

Other unexpected costs to consider: a covered entrance, emergency power, air filtration, and accessible parking and delivery areas. To prevent unexpected costs, have an architect look at any space you are considering before you enter into an agreement for it, suggests William Massingill, an architect with Polkinghorn Group Architects, in Austin, Texas.

"The days of build-it-and-they-will-come are over. Before you start designing anything, you must determine if you have enough cases to keep the center alive and profitable," says Mr. Gordon.

Start by having a good idea of the kind and number of procedures you'll do, and the estimated reimbursements for them, Mr. Terry says. In a multi-specialty center, you can estimate about eight cases to 10 cases a day per OR, or around 900 cases per year per OR.

Your procedure mix will determine the applicable guidelines for your ORs. Mr. Terry explains how the American Institute of Architects' regulations classify ORs into A, B or C based on the type of anesthesia used in the room:

• Class A is the least restrictive and is used for local anesthesia - basically your procedure rooms.
• In a class B room, you can administer conscious sedation.
• Class C, used for general anesthesia, requires the largest room size and has the most restrictive guidelines.

With the feasibility study, you must also determine the licensure and certification you're seeking, so decide on those early. "You must determine which licensure, certification and accreditation your center is seeking in order to complete a program assessment. Your state public health department will determine the minimum construction standards. More regulations may be required depending on which certification process you see," says Jeff Eckert, architect with Eckert Wordell Architects in Kalamazoo, Mich.

Your total costs should include

• construction (contractor, bricks and mortar)
• professional fees (architect, engineers, equipment planner, lawyer, consultant)
• equipment;
• furnishings and fixtures;
• administrative fees (permits, connection fees, surveys, regulatory fees and borrowing fees like appraisals, points and inspection costs) and
• land costs (site and site development costs).

Space programming
During the programming phase, develop a list of rooms and determine their number, sizes and functions, from entry, business and support areas, ORs, and pre- and post-op rooms.

Most architects agree that determining the number of pre-op and recovery rooms is as critical as the number of ORs because the same potential for bottlenecking exists there. "In the morning, you have more pre-op than post-op patients," says Mr. Gordon. "If you have two pre-op rooms and two recovery rooms per OR, equip them with the same beds and supplies and you can use them interchangeably." Using this system, you can also centralize the nurses station and share one station between the two areas, says Mr. Cantrell.

This phase is also when you begin to talk about patient, staff and material flow. "The greatest impact that we as healthcare design specialists have is in designing for optimal staffing levels. Saving one full-time employee through efficient design can mean a savings of over one million dollars over the term of the finance for the facility," says John Hrivnak, an architect at Altus Architectural Studios in Omaha, Neb.

Mr. Terry advises you go on field trips to existing facilities so you can walk through and, in addition to finding out what you like and dislike, see the flow and efficiency-improvement opportunities of the center.

"Your architect should understand your daily activities and have innovative ideas for how to allow for more efficient work flow," says Tim Riddle, architect with Boulder Associates, in Boulder, Colo. "For example, where do you put the gurney during a procedure? Many facilities wheel it out to the?sterile corridor, because this is the way it has always been done. Designing a place to store it in the OR may save time and prevent overcrowding in the hall."

Also consider the patient experience, says Mr. Cantrell. The presence of natural light can improve overall patient satisfaction, but it can difficult to bring in everywhere. Choose?places where it is most appreciated, such as?in the waiting room and recovery areas, says Mr. Riddle. Other patient-friendly amenities include private consultation areas and Internet access in the waiting room.

"Some clients want to go overboard and create a lavish spa-like setting for patients, but there is a fine balance," says Mr. Massingill. "Investors want a quick return on their investment, and the more money that goes into the center, the longer it will take to see a return."

Schematic design
During this phase, the architect draws up the floor plan - and the state agency might already be involved, depending on your location. "We recommend the state's being involved at the beginning so it can interpret codes and regulations," says Mr. Eckert. "By involving these individuals early in the process, we have found this approach will many times shorten and guarantee a successful review process."

Once the floor plan is finished, architects begin to add details, like cabinetry and finishes, and lay out equipment locations. "A lot of this is done with computer programs and 3-D models to give the client a feel for how it will look and function," says Mr. Terry.

Follow these tips and, with state and local approval in hand, you'll be on your way to completing what will hopefully be a successful surgery center.